Plastic Surgery
Dr.Ahmed Nawres
Greek word (Plastikos): means" to form or mold".
Includes: Reconstructive surgery
Aesthetic (Cosmetic) surgery.
Reconstructive surgery:
Performed on abnormal structures of the body. Usually concerned with repair
of deformities (due to trauma, tumor, infection, congenital anomalies, and
diseases) and correction of functional deficits.
Aesthetic (Cosmetic ) surgery:
Performed on normal structures of the body. It is surgery of appearance or
body image surgery. Usually concerned with repair or reshape the normal
structures of the body, to improve appearance and self esteem.
Field of Reconstructive Surgery:
1: Burn: management of acute burn and its chronic complication.
2: Congenital anomalies: e.g. cleft lip, cleft palate, Bat ear.
3: Reconstruction of defects in skin and soft tissues e.g. congenital defect as cutis
aplasea, or acquired defects as: bed sore, traumatic loss, surgical defect after
tumor resection, breast reconstruction after mastectomy…etc.
4: Hand surgery: e.g. Congenital hand deformities e.g. syndectely, polydectely.
5: Microsurgery and replantation.
Field of Aesthetic Surgery:
1: Rhinoplasty.
2: Facial procedures: e.g. blepharoplasty, face lift.
3: Breast Surgery: Reduction mammoplasty, Augmentation mammoplasty.
4: Body Contouring Surgery: e.g. abdominoplasty, Liposuction.
Basic Techniques and principles in plastic surgery
How to assess a reconstructive problem?
By(1):correct diagnosis.
(2): determine the extent and type of missing tissues.
(3): formulate a plan for reconstruction by using a "Reconstructive Ladder".
Reconstructive Ladder
: Begins with the simplest one followed progressively by a more complex one.
: Healing by secondary intensiondirect closureskin graftlocal
flapdistant flapfree flap.
:some time a higher option is chosen e.g. local flap chosen over a skin graft to
reconstruct a nasal defect because it may provide a superior result.
: Special procedures e.g. skin traction, tissue expansion, vacuum assisted closure.
Factors influencing scar formation:
1. Race and Individual genetic makeup.
Keloid is more in Chinese and African.
2. Type of the skin:
Oily pigmented skin unsightly scar.
3. Age of the patient.
Skin loses its elasticity with increasing agewrinklingso make scars in older pt less
obvious and less prone to stretching. As a rule, the quality of the scar is better the older
the patient is at the time of the surgical excision.children's scars remain red and
hypertrophic for long periods of time.
4. Anatomical site on the body.
At extensor surface of joint e.g. knee , elbow, wrist stretched scar.
While eyelids scars almost always heals with a fine line scar.
Increased keloid risks at: presternal area, especially in female.
Over the deltoid insertion at the shoulder.
Subcutaneous border of the mandible
External ear.
5. Co-morbid conditions and nutritional status.
.protein depletion, anemia.Affect wound healing.
.vit.A: reverse the healing retardation caused by steroids.
.vit.C deficiency scarvy: characterized by failure of collagen synthesis.
.Zinc: required for epithelialization and fibroblast proliferation.
.Ferrous iron and copper: necessary for normal collagen metabolism.
6. Placement of incision (i.e. direction of the wound) i.e. proper
planning.
Parallel to Langer's Line, relaxed skin tension lines (RSTL).
Wrinkle lines are generally the same as the RSTL.
7. Surgical techniques used for closure of skin wounds.
Notice: Ultimately, however, scar formation is unpredictable even with meticulous
technique.
Surgical techniques used for closure of skin wounds
(1): Adequate local anesthesia: with or with out diluted adrenaline, except in
digit.
(2): Correct preoperative planning:
Will confirm whether the wound can be closed primarily without tension or need
skin graft, local flap…etc.
Correct plan with removal of proper safe margin in case of tumor resection e.g.
1mm in benign lesion, 5mm in BCC,10mm in SCC,30 mm or more in MM.
(3): Proper haemostasis.
(4): Minimal damage to skin edge with atraumatic technique.
(5): Debridement of necrotic tissues or foreign material.
(6): Irrigation: rapid jet lavage with normal saline.
(7): Method of suturing (suturing techniques):
.Type of skin closure: sutures, staples, steristrips, wound adhesive.
.Tension free closure.
.Wound closed in layers.
.Subcutaneous fat sutures: reduce dead space but have no effect on reducing
Wound tension in the skin. May lead to ischemia of the tissue and increase
Risk of infection.
.Dermal stitches: provide strength and relieve the tension on the wound edges.
.All sutures that do not exit the skin should be buried.
.Avoid (cross hatch stitch marks) and (punctate marks).
(8): Method of excision:
.Simple elliptical excision: 3/1 or 4/1 to avoid dog ear.
.Wedge excision:
Excision of skin lesions in special anatomical areas e.g. lips, eyelids, alar
Margin of the nose i.e. lesions in close proximity to an orifice should be
Excised at right angle to the margin of the orifice by a wedge excision
While excision parallel to the margin will produce a deformity like
Ectropion.
1/3rd of lower lip and 1/4th of the upper lip and eyelids can be excised
With primary closure.
.Circular excision:
The defect closed with skin graft or local flap.
.Multiple excision technique:
Serial excision or tissue expansion is used for large lesions e.g.
Congenital hairy nevus.
(9): Scar revision by:
Z plasty, W plasty, Dermobrasion…etc.
Z Plasty
.Is an ingenious principle used to: (Revise, Elongate, Change direction) of the
scar.
.Used for correction of band contractures, rather than mass contractures.
.Requires elasticity of the surrounding tissue
.Involve transposition of 2 triangular flaps.
.The limbs of the Z must be = to the central limb, but can extend at varying
Angles (from 30 to 90 degree) depend on the desired gain in length.
.The classic Z plasty: 60 degree angle.
Give 75% theoretical gain in length of the central limb by
Recruiting lateral tissues. The actual gain is based on the
Mechanical properties of the skin and is always less.
.The resulting central limb after flap transposition will be perpendicular to the
Original central limb .In scar revision, the final central limb should lie in the
Direction of the skin line and should be selected first.
.Uses:
1: Release of longitudinal scar band contractures specially in cases in which the scar
Crosses a flexion creases.
2: Multiple Z plasty  break up the appearance of a straight line scar e.g. at face.
3: Congenital skin webs.
4: (U shaped) or (Trap door) scars.
5: Circumferential scars e.g. constricting bands of the extremities.